HomeMy WebLinkAbout967907The State of Wyoming
County of Sweetwater
RECEIVED 11/13/ ^11 1:13 PM
RECEIVING v07
BOOK: 798 PAGE: 30
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
ss.
AFFIDAVIT of SURVIVORSHIP
COMES NOW Gerald D. Belgarde, and after having been duly sworn upon his
oath, deposes and says as follows:
1. He is the surviving spouse of Rochelle Faye Belgarde, also known as
Rochelle F. Belgarde; and formerly known as Rochelle F. Coleman.
2. Rochelle Faye Belgarde, died in Lincoln County, Wyoming on July 10, 2012,
as is more particularly shown by the certified copy of the Certificate of Death attached
hereto and by this reference made a part hereof.
3. At the time of death of Rochelle, she was the joint owner with Affiant of the
following described property:
Lots 8,9, and 10, Block 8 of the Town of La Barge, formerly Tulsa, Lincoln
County, Wyoming, together with all improvements, appurtenances, hereditaments and
all other things thereunto belonging or in anywise appertaining, subject, however to all
easements, rights of way, covenants, reservations of record, or visible upon inspection.
4. The ownership as joint tenants of said property vested in Rochelle F.
Belgarde and Gerald D. Belgarde as a result of a conveyance by Quitclaim Deed on
October 29, 2003 from "Rochelle F. Coleman, now known as Rochelle F. Belgarde" to
"Rochelle F. Belgarde and Gerald D. Belgarde, wife and husband."
5. Rochelle F. Belgarde, who died on July 10, 2012 as above recited, is the
same person who is named in said Deed transferred by Rochelle F. Coleman, nka
Rochelle F. Belgarde; and whose death terminated her ownership of said property.
Ownership of said property now vests exclusively in Gerald D. Belgarde.
6. No application for the appointment of a personal representative is pending or
has been granted in any jurisdiction.
7. More than thirty days have elapsed since the death of decedent.
8. Any person or institution transferring property of the decedent in accordance
with this affidavit shall be held harmless and a receipt from the distributees is a valid
and sufficient release and discharge for any such person or institution in regard to
transferred property.
DATED this 27 day of September, 2012
State of Wyoming
County of Sweetwater
ss.
The foregoing Affidavit of Survivorship was subscribed and sworn to before me
this 27 day of September, 2012, by Gerald D. Belgarde.
Witness my hand and official seal.
ANGELA GONZALEZ
Notary Public
Uinta County, Wyo..mi
My Commission Expires
My Commission Expires: S81/ (o
October 26, 2012
Gerald D. Belgarde
000;1
00032
Decedent:
Name:
Gender:
Date of Birth:
Certifier:
Type:
Name:
.Address;
Date Filed:
ti
Date and Place of Death:
Date of Death:
City of Death: La. Barge
Location: .254 LaBarge Street
Additional Decedent Information:
Place of Birth:
Residence:
Marital Status:
Armed Forces:
Name of Father::
Name of Mother:
Informant:
Disposition:
Method of Disposition:
Place of Disposition:
Funeral Home or Facility
Facility:
Cause of Death:
Other Significant
Conditions:
Manner of Death: Natural Death
6452
4: CERTIFICATION OF VITAL RECORD
ST-ATE OF WYOMING
Rochelle Faye Belgarde
Female
February 22, 1953
July 10, 2012 (Approx)
Big. Timber, Montana
La/Barge, Wyoming.
Married Gerard D. Belgarde
No
Charles Douglas Morgareidge
Edwina Marie Osterhout
Gerald D. Belgarde
Burial 1
Viola Cemetery, La Barge, Wyoming
Ball Family Chapel; Evanston Wyoming
The immediate cause is listed on the first line followed by any underlying caigses,
(a) Cirrhosis of the Live
(b) Alcoholism
Dehydration
Coroner
Cliff Boyd, Deputy
274 N St, Box 57, Grover Wyoming, 83122
July 30, 2012
This is a true certification of the document on file in the office of Vital
Statistics Services, Cheyenne, Wyoming.
DATE ISSUED:Tuesday, August 07, 2012
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
State File Number:
Social Security, Number:
Age at the Time of Death:
County of Death:
Time ofDeath:
59 years
Lincoln
Hiasband
Interval:;;
Approximate 12:00 ±12hrs
This copy is not valid unless prepared on papa, with as engraved border r 1, '4;/,
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James McBride
Deputy State Registrar
2012- 002213